Lateral Extra-Articular Tenodesis (LET) with ACL Reconstruction

Overview

A lateral extra-articular tenodesis (LET) is a soft-tissue procedure on the outer side of the knee, added to ACL reconstruction to control rotational instability that the ACL graft alone does not fully address. Dr. Raffo, who performs a high volume of ACL reconstruction for patients across Bethesda, Germantown, and the rest of Montgomery County, adds an LET to most high-risk pivoting athletes because randomized trial data show a large reduction in both graft rupture and overall clinical failure.

How Dr. Raffo Performs This Procedure

LET is performed through a small separate incision on the outer side of the knee, typically using a strip of the iliotibial band left attached distally (the modified Lemaire technique) or a similar lateral graft, which is passed under the lateral collateral ligament and fixed to the femur near the ACL graft's femoral tunnel, tensioned with the knee in a specific degree of flexion and rotation. It is done in the same operative setting as the ACL reconstruction, adding time to the procedure but not requiring a separate surgery or separate recovery period. Adding LET has not been shown to increase adverse events or reduce range of motion compared with ACL reconstruction alone (Heard et al., J ISAKOS 2023).

Who Is This For?

• Young, active patients receiving a hamstring autograft, especially those returning to pivoting or cutting sports, are strongly indicated for LET by expert consensus (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
• Patients with a grade III pivot shift, generalized ligamentous laxity with knee hyperextension, or skeletal immaturity are also strongly indicated for LET (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
• Revision ACL reconstruction and chronic ACL deficiency are recommended indications (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
• Young, active patients receiving a bone-patellar tendon-bone or quadriceps tendon graft, pivoting-sport athletes generally, grade 3 Lachman, posterior tibial slope greater than 12 degrees, and a history of contralateral ACL injury fall into the "should be considered" tier — a real but softer indication (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
• Patients with a normal pivot shift, no hyperextension, low-demand activity goals, or significant pre-existing lateral compartment arthritis are generally not candidates — the added surgical time and the unresolved long-term joint question are harder to justify without a clear risk factor.

Recovery & Rehabilitation

Recovery after ACL reconstruction with LET follows the same criteria-based framework as ACL reconstruction alone, since STABILITY found no difference in range of motion between the two groups. Patients should expect somewhat more discomfort in the first 3 to 6 months at the lateral incision site, which resolves without a measurable difference in activity scores by 2 years.

• Weeks 0–2: Early motion and weightbearing; more soft-tissue discomfort at the lateral incision than with ACL reconstruction alone, typically manageable with standard postoperative pain control.
• Weeks 3–6: Progressive closed-chain quadriceps strengthening, as with any ACL reconstruction.
• Months 3–6: The period of measurably increased pain reported in STABILITY resolves; sport-specific agility work begins later in this window.
• Months 6–9: Formal strength and hop testing.
• Month 9 and beyond: Return to pivoting sport only after passing a strength and hop-test battery — the same threshold used for ACL reconstruction without LET (Grindem et al., BJSM 2016).